I fell into writing about health shortly after grad school, where I realized I didn't want to work in a lab for the rest of my life! My areas of interest are the brain and behavior, as well as what influences the decisions we make about our health, and how the media helps and hinders people's understanding of health issues. As an undergraduate, I studied English Literature and Biopsychology at Vassar College, and got my PhD in Biopsychology and Behavioral Neuroscience at CUNY's Graduate Center in New York City, where I grew up and live now. My day job is as Associate Editor with the health website, TheDoctorWillSeeYouNow.com. My work has appeared in several other publications, including TheAtlantic.com and YogaGlo.com, and I'm particularly excited to join the Forbes health team. Email me at alicegwalton [at] gmail [dot] com .

More Kids Than Ever Are On Antipsychotics: But Is There An Alternative?

Photo credit: dullhunk

A widely reported new study finds that more kids and teens are being prescribed antipsychotic medications than ever before. Many of these prescriptions are for “off-label” uses – those not approved by the FDA – like treatment for ADHD. Given the fact that we don’t know a whole lot about how these meds affect the brain over the long term, should we be so quick to put our kids on them? On the other hand, this issue begs another obvious one: What’s the alternative?

In children and adolescents, antipsychotic medications are approved only for treatment of bipolar disorder (in kids 10-17), schizophrenia (in kids 13-17), the irritability that can accompany autism, and the “tics and vocal utterances of Tourette syndrome.”

So the fact that their prescription has risen so markedly in recent years means that that “the range of mental disorders treated with these medications in practice has broadened,” according to the authors of the new paper. “In young people, attention-deficit/hyperactivity disorder and other disruptive disorders account for a substantial proportion (37.8%) of antipsychotic use.” Again, these drugs are not actually approved to treat these disorders, making these “off-label” uses for the class of drugs.

In fact, antipsychotic meds for kids jumped sevenfold between the years 1993-1998 and 2005-2009. For teens, it almost quintupled. For adults, it only doubled.

What’s known about side effects mainly has mainly to do with the body’s metabolism. Young people are at risk of weight gain, lipid abnormalities, and antipsychotic-associated diabetes.

The long-term effects of the medications on the developing brain are, bizarrely, less clear. Some critics have condemned the use of antipsychotics in young people, arguing that they disrupt normal brain development. “We have a national catastrophe,” Peter Breggin told HealthDay. “This is a situation where we have ruined the brains of millions of children.”

Unfortunately, we don’t exactly know that this is true. Although one might guess that there may be some developmental effects of antipsychotic exposure over the long-term, given that the brain develops right through the teen years and beyond, there is little evidence to back up the claim.

The problem is that we don’t know the negative long-term effects of the medications because we don’t know any long-term effects of the medications. “Long-term studies of medication exposure are rare,” study author Mark Olfson, MD, told me, “because they are not required by the FDA or other regulatory agencies for drug approval and they are also exceedingly difficult to perform.” Many of the meds are too new to have long-term studies, but the fact that the FDA also doesn’t require them is a bit perplexing.

The effects of long-term use of antipsychotics in kids are difficult to monitor partly because there’s a lot of trial-and-error that can occur when treating a child for behavioral problems. “Because children and adolescents with ADHD change treatments frequently,” said Olfson, “it is difficult to study the effects of the consistent application of stimulants or other treatments. Findings from the NIMH MTA (Multimodal Treatment Study of Children with ADHD) demonstrate benefits from stimulant medication for over a year, but when the definition of long-term is extended to 3 years, the superiority of medications appears to be lost.”

Another part of what makes the issue so murky is that oftentimes there is more than one diagnosis involved. Celia Blumenthal, MD, who practices at the Mount Sinai Adolescent Health Center, says that when it comes to antipsychotics in kids, “No one’s using these as a primary drugs for ADHD. If kids on typical meds for ADHD become more agitated on them, then you think there’s probably something else going on, so something else needs to be tried.”

One issue to keep in mind, she adds, is that mental health disorders in kids can present very differently from how they do in adults. Sometimes it can be hard to tease apart what exactly is going on – whether it’s ADHD, stress, depression, or a little bit of everything. “Depression and anxiety don’t present the same way in young people. For example, when a child or adolescent becomes depressed, they can become irritable and aggressive. Some might be classified as having a disruptive behavior disorder – but in the end, it may really be a mood disorder.”

Olfson agrees that the evidence does “not suggest that child psychiatrists or other physicians favor antipsychotics over stimulants for the treatment of ADHD. Nevertheless, a considerable number of children with ADHD who have not been diagnosed with other psychiatric disorders receive antipsychotics in addition to stimulants. Although it is not possible to determine the clinical motivations for prescribing antipsychotic medications in this setting, it is likely that many of these children have problematic disruptive or aggressive behaviors that persist despite stimulant treatment.”

Is there a better way? It shouldn’t come as a surprise that the answer to this question is also unclear. There’s certainly evidence that medications can help significant behavior problems in the short term. And some psychiatrists, like Blumenthal, suggest that behavior problems like ADHD can, over the years, spiral into other, even more significant issues like oppositional defiant disorder or conduct disorder. The success of purely behavioral interventions used in place of pharmaceutical ones does not seem to be known.

“Psychiatry is not an exact science,” says Blumenthal. “It’s geared towards symptom reduction, not diagnosis. Antipsychotics as a class of meds are good at making people calmer. Sometimes the symptoms themselves, beyond the diagnosis, can necessitate use of medication.”

The answers to all of these questions may take decades to unfold. In the meantime, it’s up to us, our kids, and their psychiatrists to decide whether they’re better off on or off the medications, and that’s no easy matter.